Methods of Reducing Risk of Cardiovascular Disease

ABSTRACT

Methods of lowering the plasma LDL-C levels in a patient on a stable dose of statin where the patient has an LDL-C level above treatment goal. Methods of decreasing a patient&#39;s risk for developing coronary heart disease, having a recurrent cardiovascular event or reducing the severity of a secondary cardiovascular event, wherein the patient is on a stable dose of statin and the patient has an LDL-C level above treatment goal.

CROSS REFERENCE TO RELATED APPLICATION(S)

This application claims priority to U.S. Provisional Application Ser.No. 61/584,002 filed Jan. 6, 2012. The entire content of U.S.Provisional Application Ser. No. 61/584,002 is incorporated herein byreference.

BACKGROUND OF THE INVENTION

Of all human medical health conditions, cardiovascular diseases are thesingle largest cause of morbidity and death. It is well known that theblood contains lipoproteins. These are particles responsible fortransporting non-aqueous lipids throughout the body, and are generallyclassified into four major categories with the associated generalfunctions; chylomicrons, large triglyceride containing lipoproteinsproduced by the intestine during the processes of absorbing dietary fat,very low density lipoproteins (VLDL) triglyceride-rich lipoproteinsproduced by the liver and facilitates transport of triglycerides tomuscle and adipose tissue for energy and storage, low densitylipoproteins (LDL), cholesterol-rich particles that transportcholesterol to cells for growth, repair, production of bile acids, orfor storage as cholesteryl esters as a reservoir of cholesterol forsteroid production, and finally high density lipoprotein, aphospholipid-rich lipoprotein, that facilitates removal of excesscholesterol from cells. Each type of lipoprotein is comprised of polarand nonpolar lipids as well as amphipathic apolipoproteins.

Human epidemiologic and clinical studies have demonstrated theimportance of low levels of LDL-cholesterol (LDL-C) in the preventionand treatment of cardiovascular diseases. And Epidemiologic evidence hasalso shown that high levels of HDL-cholesterol (HDL-C) play a role inpreventing cardiovascular disease. It is also believed that low levelsof very low density lipoprotein-cholesterol (VLDL-C) and plasmatriglycerides are important in the prevention of cardiovasculardiseases.

It is well known that reduction of LDL-C is an important aspect ofmedical treatment to prevent or delay the onset of cardiovasculardiseases as well as to treat existing cardiovascular diseases. Morerecently, it has been recognized that aggressive lowering of LDL-C isbeneficial in delaying and preventing additional episodes ofcardiovascular disease. Although LDL receives primary attention forclinical management, growing evidence indicates that other factors playimportant roles in determining risk for cardiovascular disease, forexample, total cholesterol levels, HDL levels, blood pressure, andsmoking status. Consideration of these risk factors is important indetermining treatment goals. In particular, it is crucial for personswith known coronary heart disease (CHD) to control multiple risk factorsresponsible for the worsening of CHD.

Risk of cardiovascular disease is estimated in a variety of ways by anumber of prognostic indicators. The Framingham Risk Score is based ondata obtained from the Framingham Heart Study and is used to estimatethe 10-year cardiovascular risk of an individual. The Framingham RiskScore is a calculated estimated risk for developing fatal or non-fatalcardiovascular event based on a composite score based on a pre-existingrisk factors, including: age, gender, systolic blood pressure level(+/−treatment), HDL cholesterol level, and smoker status. A patient'srisk score gives and indication of the likely benefits of prevention andalso can be a useful metric to determine the effects of treatments.

The 2004—Updated National Cholesterol Education Program Adult TreatmentPanel III (2004—Updated NCEP ATPIII) guidelines present treatmentguidelines for patients with elevated LDL-C, triglycerides and othergenetic or environmental risk factors. Briefly, the 2004—updated NCEPATP III treatment guidelines recommend LDL-C lowering guidance based onpre-existing conditions. The updated guidelines add the use ofFramingham projections of a 10-year absolute CHD risk to identifypatients for more intensive treatment. For subjects with 0 or 1 riskfactors, an LDL-C of less than 160 mg/dL is recommended. For subjectswith two or more risk factors and with a Framingham 10-year risk of lessthan 10 percent, an LDL-C of less than 130 mg/dL is recommended. Forsubjects with two or more risk factors and with a Framingham 10-yearrisk of 10-20%, or existing cardiovascular heart disease, orcardiovascular heart disease risk equivalents, or a Framingham 10-yearrisk of greater than 20%, an LDL-C of less than 100 mg/dL isrecommended. CHD risk equivalents include other clinical forms ofatherosclerotic disease (peripheral arterial disease, abdominal aorticaneurysm, and symptomatic carotid artery disease); diabetes; and thepresence of multiple risk factors that confer a 10-year Framingham riskfor CHD of ≥20%. For subjects with established cardiovascular diseaseand also are diabetic, or are also smokers, or also have low levels ofHDL-C and high levels of blood triglycerides, or also have metabolicsyndrome, or also have multiple risk factors, an LDL-C of less than 70mg/dL is recommended.

The difficulty of lowering the LDL-C level to less than 100 mg/dL orless in patients with known CHD has been well documented. Achieving theupdated NCEP ATP-III guidelines recommendation to reduce LDL-C levels tolower than 70 mg/dL for persons at very high risk, is even moredifficult.

In Europe, the Third Joint European Task Force (TJETF) providesrecommendations or guidelines for lowering LDL-C based on existing LDL-Clevels, total cholesterol levels, type 2 diabetes, systolic bloodpressure, diastolic blood pressure, 10-year risk score of a fatalcardiovascular event, or preexisting atherosclerotic disease.Recommendations are also provided for patients having a combination ofconditions, such as a known 10-year risk score of fatal cardiovasculardisease plus elevated plasma total cholesterol or LDL cholesterollevels. Specifically the TJETF recommends reaching an LDL-C of less than115 mg/dL if a subject's 10-year risk of cardiovascular disease is lessthan 5 percent, or has a 10-year risk of cardiovascular disease ofgreater than or equal to 5 percent and also has an existing totalcholesterol of greater than or equal to 190 mg/dL or an existing LDL-Cof greater than or equal to 115 mg/dL. The TJETF guidelines recommendsreaching an LDL-C of less than 100 mg/dL if a subject hasatherosclerotic disease, or Type 2 diabetes, or a total cholesterolgreater than or equal to 320 mg/dL, or an LDL-C greater than or equal to240 mg/dL, or has systolic blood pressure of greater than or equal to180 mm Hg, or has diastolic blood pressure of greater than or equal to110 mm Hg, or has a 10-year risk of cardiovascular disease of greaterthan or equal to 5 percent plus a total cholesterol of less than 190mg/dL and an LDL-C less than 115 mg/dL.

Although statins are drugs of choice to lower LDL-C, not all patientscan tolerate statins or can tolerate a high statin dose. In addition,approximately half of all patients on stable statin doses do not reachrecommended LDL-C lowering goals, (See, Centralized Pan-European Surveyon the Undertreatment of Hypercholesterolemia in Patient Using LipidLowering Drugs, The Cepheus-Greece Survey, Angiology (2010), Vol. 61(5), pp 465-474 and the 2004-updated NCEP ATPIII guidelines.).

Furthermore, it is well recognized, that the doubling of a statin dosein a patient already on a statin, has limited effect on further LDL-Clowering while increasing safety issues associated with a high statindose. The literature teaches that lowering cholesterol beyond thatachieved with a stable statin dose is difficult. McKenney reported thatstatins have a nonlinear dose-response relationship such that doublingthe dose of a particular statin provides only an additional 6% furtherlowering of LDL-C (American Journal of Therapeutics (2004), Vol. 11, pp55-59). While other treatments can further lower LDL-C, this furtherreduction is often not enough to bring these patients' LDL-C level downto goal. For example, the combination of a stain plus a fibrate, such asfenofibrate has little effect or has a negative effect on LDL-C beyondthe statin alone. The combinations of stains with bile acidsequestrants, such as cholestyramine, can result in lower LDL-C, howeverthe reduction is often insufficient to reach a desirable LDL-C goal andcompliance for bile acid sequestrants with patients is poor. Althoughagents such as Zetia, that block cholesterol absorption from theintestine, have shown improved LDL-C lowering when given with a statin,further lowering of LDL-C levels may be needed.

The goal for LDL-C levels under the current guidelines is guided by anassessment of the risk for developing cardiovascular heart disease orhaving a recurrence of a cardiovascular event.

Therefore there is a need for additional agents to reduce a patientsrisk for developing cardiovascular heart disease or having a recurrenceof a cardiovascular event.

SUMMARY OF THE INVENTION

Unexpectedly, we found that in patients unable to reach the recommendedgoals for LCL-C levels with statin treatment alone, the addition ofgemcabene resulted in a significant further reduction in plasma LDL-Clevels and reduction in risk based on Framingham Risk scores.

The present invention relates to additional intervention in a patientgroup wherein despite being on a stable dose of a statin, the patientsin the group have failed to achieve the relevant LDL cholesteroltreatment goal or continue to have a high-risk for developing coronaryheart disease or experiencing a recurrent cardiac event. With respect tothe present invention the additional intervention comprisesadministering a compound of formula (I), formula (II), or formula (III)alone or in conjunction with another cholesterol lowering drug. Thesecompounds are administered in conjunction with ongoing statin treatment.The addition of a compound of the invention to the ongoing statintreatment further reduces the LDL-C and results in a lowered risk fordeveloping cardiovascular disease or having a recurrent cardiovascularevent when compared to the level achieved in the absence of the compoundof the invention.

Thus, one embodiment of the invention is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of a compound of formula (I):

wherein n, m, R₁, R₂, R₃, R₄, Y₁, and Y₂, are as defined herein, or anester or a salt thereof, or a precursor thereof that metabolizes in vivoto the compound of formula (I) or the free acid, a salt, or a hydratethereof; wherein the patient is on a stable dose of statin and thepatient has an LDL-C level above treatment goal.

Another embodiment is a method of preventing, delaying the onset of, orreducing the severity of a secondary cardiovascular event comprisingadministering to a patient in need thereof, an effective amount of acompound of formula (I):

wherein n, m, R₁, R₂, R₃, R₄, Y₁, and Y₂, are as defined herein, or anester or a salt thereof, or a precursor thereof that metabolizes in vivoto the compound of formula (I) or the free acid, a salt, or a hydratethereof; wherein the patient is on a stable dose of statin and thepatient has an LDL-C level above treatment goal.

Another embodiment of the invention is a method of lowering LDL-C levelin a patient on a stable dose of statin, the patient having an LDL-Clevel above treatment goal, comprising administering to the patient, aneffective amount of a compound of formula (I):

wherein n, m, R₁, R₂, R₃, R₄, Y₁, and Y₂ are as defined herein, or anester or a salt thereof, or a precursor thereof that metabolizes in vivoto the compound of formula (I) or the free acid, a salt, or a hydratethereof.

Additional embodiments are described herein.

BRIEF DESCRIPTION OF THE DRAWING

FIG. 1. Shows the additional lowering of LDL-C levels in patients notreaching treatment goals on statin alone resulting from the addition ofgemcabene. Bar A of the graph represents statin treatment alone; Brepresents statin+300 mg gemcabene; and C represents statin+900 mggemcabene.

DETAILED DESCRIPTION OF THE INVENTION

As used herein, the term “carboxyalkylether” includes the free acid,pharmaceutically acceptable salts and esters thereof, and prodrugsthereof that are converted to the free acid, or salt or hydrate thereof.Such compounds are known in the art, as well as their synthesis andformulation.

“Subject” or “Patient” are used interchangeably.

The term “treating” or other forms of the word such as “treatment”, or“treat” is used herein to mean that administration of a compound of thepresent invention mitigates a disease or a disorder in a host and/orreduces, inhibits, or eliminates a particular characteristic or eventassociated with a disorder (e.g., reduced steroidogenesis). Thus, theterm “treatment” includes, preventing a disorder from occurring in ahost, particularly when the host is predisposed to acquiring thedisorder; inhibiting the disorder; and/or alleviating or reversing thedisorder. Insofar as the methods of the present invention are directedto preventing disorders, it is understood that the term “prevent” doesnot require that the disease state be completely thwarted. Rather, asused herein, the term preventing refers to the ability of the skilledartisan to identify a population that is susceptible to disorders, suchthat administration of the compounds of the present invention may occurprior to onset of a disease. The term does not imply that the diseasestate be completely avoided.

“HDL-C” is an abbreviation for high density lipoprotein cholesterol.

“LDL-C” is an abbreviation for low density lipoprotein cholesterol.

“LDL-C level” is used interchangeably with “plasma LDL-C level”.

“VLDL-C” is an abbreviation for very low density lipoproteincholesterol.

Throughout the description and claims of this specification the word“comprise” and other forms of the word, such as “comprising” and“comprises,” means including but not limited to, and is not intended toexclude, for example, other additives, components, integers, or steps.

As used herein, the singular forms “a”, “an”, and “the” include pluralreferences unless the context clearly dictates otherwise.

“Between” as used herein is inclusive, e.g., “between 1 mg and 5000 mg”includes 1 mg and 5000 mg.

“About” when used in conjunction with a number includes the numberitself, for example, “from about 1 mg to about 5000 mg” includes therange “from 1 mg to 5000 mg”.

“From” as used herein is inclusive, e.g., “from 1 mg to 5000 mg”includes 1 mg and 5000 mg.

“Alkyl” means a saturated aliphatic hydrocarbon containing 1-6 carbonatoms. An alkyl can be straight or branched.

“Alkenyl” means an aliphatic carbon that contains 2-6 carbon atoms andat least one double bond. Like an alkyl, an alkenyl can be straight orbranched.

“Alkynyl” means an aliphatic carbon that contains 2-6 carbon atoms andat least one triple bond. Like an alkyl, an alkynyl can be straight orbranched.

The term “carbocyclic ring” encompasses cycloalkyl and cycloalkenylrings. Carbocyclic rings can be optionally substituted with one or moresubstituents such as aliphatic (e.g., alkyl, alkenyl, or alkynyl).

An “effective amount” is that amount of the compound, orpharmaceutically acceptable composition thereof, which is effective tolower plasma LDL-C levels and/or to reduce a patient's Framingham RiskScore.

“CHD” is an abbreviation for Coronary Heart Disease.

Reference to “a patient on a stable dose of a statin” means that thepatient has been treated with a statin for a period sufficient for oneof skill in the art to determine that the patient has reached a stableLDL-C level at a defined dose of a statin.

Patients at high risk for CHD or a recurrent cardiac event, includewithout limitation, persons with CHD (history of myocardial infarction,unstable angina, stable angina, coronary artery procedures, (such asangioplasty or bypass surgery, or evidence of clinically significantmyocardial ischemia)) or CHD risk equivalents which include clinicalmanifestations of non-coronary forms of atherosclerotic disease, (suchas peripheral arterial disease, abdominal aortic aneurysm, and carotidartery disease), diabetes, with 2 or more risk factors and a Framingham10-year risk of developing CHD greater than 20%.

Patients at very high-risk for CHD or a recurrent cardiovascular event,include patients that have had a recent heart attack, or those who havecardiovascular disease combined with either diabetes, or severe orpoorly controlled risk factors (such as continued smoking), or metabolicsyndrome.

Cardiovascular diseases include, without limitation, coronary arterydisease, cerebral vascular disease, such as stroke, peripheral vasculardisease, or any diseases pertaining to an abnormal condition of theheart or circulatory system.

“Plasma LDL-C level” and “LDL-C level” are used interchangeably herein.

Statins are drugs that inhibit 3-hydroxymethylglutaryl coenzyme Areductase (HMG CoA reductase).

In 2002, the National Cholesterol Education Program (NCEP) published areport on detection, evaluation, and treatment of high blood cholesterolin Adults (NCEP ATP III) (NIH Publication No. 02-5215). In 2004, theNCEP issued updated recommendations (updated National CholesterolEducation Program Adult Treatment Panel III (2004—Updated NCEP ATPIII)guidelines). Treatment goals as defined in the updated guidelines arebased on a patient's estimated risk for developing CHD. In summary, thegoal for high-risk patients having CHD or a CHD risk equivalent, is anLDL-C level of less than 100 mg/dL. The goal for patients having two ormore risk factors, is an LDL-C level of less than 130 mg/dl. The goalfor patients having zero or one risk factor, the goal is an LDL-C levelof less than 160 mg/dL. For very high-risk patients there is atherapeutic option where the recommended goal is an LDL-C level of lessthan 70 mg/dL. Risk factors include smoking, hypertension (Bloodpressure of ≥140/90 mmHg or on antihypertensive medication), low HDLcholesterol (<40 mg/dL), family history of premature CHD (CHD in malefirst degree relative <55 years; CHD in female first degree relative <65years), and age (men ≥45 years; women ≥55 years). Patients with veryhigh-risk are those who have had a recent heart attack, or those whohave cardiovascular disease combined with either diabetes, or severe orpoorly controlled risk factors (such as continued smoking), or metabolicsyndrome.

A patient achieves an LDL cholesterol treatment goal when the patient'sLDL-C level meets a recommended level as defined by the 2004-UpdatedNCEP ATPIII guidelines.

As used herein, references to 10-year risk are calculated using theFramingham point scores as provided in Tables 1 and 2, for men and womenrespectively.

TABLE 1 Estimate of 10-Year Risk for Men (Framingham Point Score) AgePoints 20-34 −9 35-39 −4 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-6911 70-74 12 75-79 13 Total Points Cholesterol Age 20-39 Age 40-49 Age50-59 Age 60-69 Age 70-79 <160  0 0 0 0 0 160-199  4 3 2 1 0 200-239  75 3 1 0 240-279  9 6 4 2 1 ≥280 11 8 5 3 1 Points Age 20-39 Age 40-49Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 8 5 3 1 1 HDL(mg/dL) Points ≥60 −1 50-59 0 40-49 1 <40 2 Systolic BP If (mmHg)Untreated If treated <120 0 0 120-129 0 1 130-139 1 2 140-159 1 2 ≥160 23 10-Year Point Total Risk %  <0 <1    0 1    1 1    2 1    3 1    4 1   5 2    6 2    7 3    8 4    9 5   10 6   11 8   12 10   13 12   14 16  15 20   16 25 ≥17 ≥30

TABLE 2 Estimate of 10-Year Risk for Women (Framingham Point Score) AgePoints 20-34 −7 35-39 −3 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-6912 70-74 14 75-79 16 Total Points Cholesterol Age 20-39 Age 40-49 Age50-59 Age 60-69 Age 70-79 <160  0  0 0 0 0 160-199  4  3 2 1 1 200-239 8  6 4 2 1 240-279 11  8 5 3 2 ≥280 13 10 7 4 2 Points Age 20-39 Age40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 9 7 4 2 1HDL (mg/dL) Points ≥60 −1 50-59 0 40-49 1 <40 2 Systolic BP If (mmHg)Untreated If treated <120 0 0 120-129 1 3 130-139 2 4 140-159 3 5 ≥160 46 10-Year Point Total Risk %  <9 <1    9 1   10 1   11 1   12 1   13 2  14 2   15 3   16 4   17 5   18 6   19 8   20 11   21 14   22 17   2322   24 27 ≥25 ≥30

The present invention relates to additional intervention in a patientgroup wherein despite being on a stable dose of a statin the patients inthe group have failed to achieve the relevant LDL cholesterol treatmentgoal. With respect to the present invention, the additional interventioncomprises administering a compound of formula (I), formula (II), orformula (III) alone or in conjunction with another cholesterol loweringdrug. These compounds of formula (I), formula (II), or formula (III) arereferred to throughout the specification and claims as “compounds of thepresent invention” or “compounds useful in the present invention”.

In addition to LDL-C, other molecules play a role in the regulation ofcholesterol. For example, ABCA1 is a cell membrane protein responsiblefor the transfer of cholesterol to HDL and thus plays a function in theassembly of HDL. ABCA1 deficiency is the metabolic basis of Tangier'sdisease which is characterized by low levels of HDL cholesterol,accumulation of lipid in organs, and premature atherosclerosis.Increased expression of ABCA1 can result in elevation of HDL cholesteroland reduced cardiovascular disease progression. PCSK9 is an LDL receptorassociated protein that allows the receptor to undergo degradationfollowing endocytosis. Binding PCSK9 with specific monoclonal antibodiesallows recycling of the LDL receptor leading to a more efficient removalof LDL cholesterol. Targeting PCSK9 using DNA, antisenseoligonucleotides, siRNA, microRNA, or small molecule inhibitors may alsolead to reduced LDL cholesterol levels. PCSK9 inhibitors are known inthe art, including but not limited to AMG 145 (Amgen), RN316(Pfizer/RInat), RG7652 (Roche/Genentec), REGN727 (Sanofi/Regeneron).Therefore, one embodiment is a method of lowering the plasma LDL-C levelin a patient on a stable dose of statin, the patient having an LDL-Clevel above treatment goal, comprising administering to the patient, aneffective amount of a compound of formula (I) in combination with aPCSK9 inhibitor. Another embodiment is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patientan effective amount of a compound of formula (I) in combination with aPCSK9 inhibitor. Yet another embodiment is a method of preventing,delaying the onset of, or reducing the severity of a secondarycardiovascular event, comprising administering to a patient in needthereof, an effective amount of a compound of formula (I) in combinationwith a PCSK9 inhibitor.

In addition, ABCA1 elevating compounds are known, see for example U.S.Pat. No. 7,579,504, which is hereby incorporated by reference in itsentirety. Embodiments of the invention therefore include embodimentswherein a compound of the present disclosure is administered incombination with an agent that elevates ABCA1 levels.

Several groups have disclosed that MicroRNAs play important roles inregulating cholesterol and fatty acid metabolism. MicroRNA are shortnon-coding RNAs that act as post-transcriptional regulators. A number ofmicroRNAs have been identified. In particular, miR-33 has been shown toinhibit the expression of ABCA1. Targeted inhibition of microRNA-33results in increased expression of ABCA1, elevated HDL cholesterol, andinhibition of atherosclerosis in mice. (see Rayner et al., Science vol.328, 2010) In non-human primates, targeted inhibition of microRNA-33results in elevated HDL-C and reduced LDL-C. Embodiments of theinvention therefore include embodiments wherein a compound of thepresent disclosure is administered in combination with an agent thatinhibits miR-33.

Another protein involved in cholesterol metabolism is MicrosomalTransfer Protein-1 (MTP-1) which is an intracellular protein thatfacilitates the transfer of triglycerides to chylomicrons and VLDLduring their assembly. The genetic deficiency of MTP-1 is the metabolicbasis of the abetalipoproteinemia. The production of apolipoprotein B100or apolipoprotein B-48, which are derived from a single gene via posttranscriptional processing, are used in the assembly of VLDL andchylomicrons, respectively, and are constitutively produced and act as asurplus for use as a ready source to assemble these particles givendelivery of triglycerides via MTP-1. The lack or reduction of MTP-1markedly inhibits triglyceride delivery to the assembly process andforces the degradation of apolipoprotein B-100 or B-48 and leads toaccumulation of intracellular triglycerides. MTP-1 activity leads to afatty liver and intestinal enterocyte accumulation of triglyceride-richlipid droplets. Pharmacological inhibition of MTP-1 is being developedto decrease LDL production and to reduce levels of LDL-C in homozygousfamilial hypercholesterolemia. Embodiments of the invention thereforeinclude embodiments wherein a compound of the present disclosure isadministered in combination with an agent that inhibits MTP-1.

Depending on the dose of the compound of the invention that isadministered to the patient on a stable dose of statin, the LDL-C levelmay be further lowered by at least 15%, 16%, 17%, 18%, 19%, 20%, 21%,22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%,36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%,50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62%, 63%,64%, 65%, 66%, 67%, 68%, 69%, or 70% or at least by about 15%, about16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%,about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%,about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%,about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 61%,about 62%, about 63%, about 64%, about 65%, about 66%, about 67%, about68%, about 69%, or about 70%.

In some embodiments administration of a compound of the invention to apatient on a stable dose of statin, the LDL-C level is further loweredby about 10% to about 20%, or from about 10% to about 30%, or from about20% to about 40%, or from about 20% to about 50%, or from about 20% toabout 60%, or from about 20% to about 70%, or from about 30% to about70%, or from about 30% to about 80%, or from about 30% to about 90%,with respect to the amount LDL-C was lowered by the statin.

In one embodiment administration of a compound of the invention to apatient on a stable dose of statin, the LDL-C level is lowered to ≤240mg/dL. In another embodiment the LDL-C level is lowered to ≤200 mg/dL.In yet another embodiment the LDL-C level is lowered to ≤150 mg/dL. Instill another embodiment the LDL-C level is lowered to ≤140 mg/dL. Inanother embodiment the LDL-C level is lowered to ≤130 mg/dL. In yetanother embodiment the LDL-C level is lowered to ≤115 mg/dL. In anotherembodiment the LDL-C level is lowered to ≤70 mg/dL.

It will be understood by one of skill in the art that any furtherreduction of LDL-C that brings the patient's LDL-C level closer to goalis desirable. It is not necessary that the combination of the statin anda compound of the invention lowers LDL-C to the treatment goal in orderfor the combination to be useful.

One embodiment of the invention is a method of lowering the plasma LDL-Clevel in a patient on a stable dose of statin, the patient having anLDL-C level above treatment goal, comprising administering to thepatient, an effective amount of a compound of the present invention.

Another embodiment of the present invention is a method of lowering theplasma LDL-C level in a patient on a stable dose of statin, the patienthaving an LDL-C level above treatment goal, comprising administering tothe patient, an effective amount of a compound of formula (I), formula(II) or formula (III), or an ester or a salt thereof, or a precursorthereof that metabolizes in vivo to the compound of formula (I), or thefree acid, a salt, or a hydrate thereof.

One embodiment of the invention is a method of lowering the plasma LDL-Clevel in a patient on a stable dose of statin, the patient having anLDL-C level above treatment goal, comprising administering to thepatient, an effective amount of a compound of formula (I):

wherein n, and m independently are integers from 2 to 9; each occurrenceof R₁, R₂, R₃, and R₄ is independently C₁-C₆ alkyl, C₂-C₆ alkenyl, C₂-C₆alkynyl, or R₁ and R₂, taken together with the carbon to which they areattached, form a carbocyclic ring having from 3 to 6 carbons, or R₃ andR₄ together with the carbon to which they are attached, form acarbocyclic ring having from 3 to 6 carbons; Y₁ and Y₂ independently are—COOH, —CH₂OH, tetrazole, and —COOR₅; R₅ is C₁-C₆ alkyl, C₂-C₆ alkenyl,C₂-C₆ alkynyl; or an ester or a salt thereof, or a precursor thereofthat metabolizes in vivo to the compound of formula (I) or the freeacid, a salt, or a hydrate thereof.

Another embodiment of the invention is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of a compound of the invention, wherein the patientis on a stable dose of statin and the patient has an LDL-C level abovetreatment goal. In particular embodiments, the risk score is accessedusing the Framingham Risk Score equation. In one embodiment thepatient's Framingham Risk Score is reduced by between about 1 and about2 points when compared with treatment with statin alone. In anotherembodiment the patient's Framingham Risk Score is reduced by betweenabout 2 and about 3 points when compared with treatment with statinalone. In another embodiment the patient's Framingham Risk Score isreduced by between about 3 and about 4 points when compared withtreatment with statin alone. In yet another embodiment the patient'sFramingham Risk Score is reduced by ≥1 point. In still anotherembodiment the patient's Framingham Risk Score is reduced by ≥2 points.In another embodiment the patient's Framingham Risk Score is reduced by≥3 points. In another embodiment the patient's Framingham Risk Score isreduced by ≥4 points.

Another embodiment of the invention is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of a compound of formula (I), formula (II) orformula (III), or an ester or a salt thereof, or a precursor thereofthat metabolizes in vivo to the compound of formula (I) or the freeacid, a salt, or a hydrate thereof, wherein the patient is on a stabledose of statin and the patient has an LDL-C level above treatment goal.

Another embodiment of the invention is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of a compound of formula (I):

wherein n, and m independently are integers from 2 to 9; each occurrenceof R₁, R₂, R₃, and R₄ is independently C₁-C₆ alkyl, C₂-C₆ alkenyl, C₂-C₆alkynyl, or R₁ and R₂, taken together with the carbon to which they areattached, form a carbocyclic ring having from 3 to 6 carbons, or R₃ andR₄ together with the carbon to which they are attached, form acarbocyclic ring having from 3 to 6 carbons; Y₁ and Y₂ independently are—COOH, —CH₂OH, tetrazole, and —COOR₅; R₅ is C₁-C₆ alkyl, C₂-C₆ alkenyl,C₂-C₆ alkynyl; or an ester or a salt thereof, or a precursor thereofthat metabolizes in vivo to the compound of formula (I) or the freeacid, a salt, or a hydrate thereof; wherein the patient is on a stabledose of statin and the patient has an LDL-C level above treatment goal.

Another embodiment is a method of preventing, delaying the onset of, orreducing the severity of a secondary cardiovascular event comprisingadministering to a patient in need thereof, an effective amount of acompound of the present invention, wherein the patient is on a stabledose of statin and the patient has an LDL-C level above treatment goal.

Another embodiment is a method of preventing, delaying the onset of, orreducing the severity of a secondary cardiovascular event comprisingadministering to the patient, an effective amount of a compound offormula (I), formula (II) or formula (III), or an ester or a saltthereof, or a precursor thereof that metabolizes in vivo to the compoundof formula (I) or the free acid, a salt, or a hydrate thereof, whereinthe patient is on a stable dose of statin and the patient has an LDL-Clevel above treatment goal.

Yet another embodiment is a method of preventing, delaying the onset of,or reducing the severity of a secondary cardiovascular event comprisingadministering to a patient in need thereof, an effective amount of acompound of formula (I):

wherein n, and m independently are integers from 2 to 9; each occurrenceof R₁, R₂, R₃, and R₄ is independently C₁-C₆ alkyl, C₂-C₆ alkenyl, C₂-C₆alkynyl, or R₁ and R₂, taken together with the carbon to which they areattached, form a carbocyclic ring having from 3 to 6 carbons, or R₃ andR₄ together with the carbon to which they are attached, form acarbocyclic ring having from 3 to 6 carbons; Y₁ and Y₂ independently are—COOH, —CH₂OH, tetrazole, and —COOR₅; R₅ is C₁-C₆ alkyl, C₂-C₆ alkenyl,C₂-C₆ alkynyl; or an ester or a salt thereof, or a precursor thereofthat metabolizes in vivo to the compound of formula (I) or the freeacid, a salt, or a hydrate thereof; wherein the patient is on a stabledose of statin and the patient has an LDL-C level above treatment goal.

In some embodiments the compound of formula (I) is administered as afree acid. In other embodiments the compound administered is apharmaceutically acceptable salt of a compound of formula (I). In yetother embodiments the compound administered is an ester of a compound offormula (I). In some embodiments the compound administered is aprecursor (pro-drug) of formula (I) that metabolizes in vivo to theactive carboxyalkylether acid or a salt of formula (I).

In some embodiments, the compound is a compound of formula I, wherein nis 2, or n is 3, or n is 4, or n is 5, or n is 6, or n is 7, or n is 8,or n is 9. In some embodiments, m is 2, or n is 3, or m is 4, or m is 5,or m is 6, or m is 7, or m is 8, or m is 9. In some embodiments, n and mare both 2, or n and m are both 3, or n and m are both 4, or n and m areboth 5, or n and m are both 6, or n and m are both 7, or n and m areboth 8, or n and m are both 9.

In some embodiments, the compound is a compound of formula I, whereinR₁, R₂, R₃, and R₄ independently are C₁-C₆ alkyl. In some embodimentsR₁, R₂, R₃, and R₄ are all C₁-C₆ alkyl. In some embodiments R₁, R₂, R₃,and R₄ independently are C₂-C₆ alkenyl. In some embodiments R₁, R₂, R₃,and R₄ independently are C₂-C₆ alkynyl. In some embodiments R₁, R₂, R₃,and R₄ are —CH₃. In some embodiments R₁, R₂, R₃, and R₄ are —CH₂CH₃. Insome embodiments R₁, R₂, R₃, and R₄ are —CH₂CH₂CH₃. In some embodimentsR₁, R₂, R₃, and R₄ are all C₂-C₆ alkenyl. In some embodiments R₁, R₂,R₃, and R₄ are all C₂-C₆ alkynyl. In some embodiments R₁ and R₂, takentogether with the carbon to which they are attached, form a carbocyclicring having from 3 to 6 carbons. In other embodiments R₃ and R₄, takentogether with the carbon to which they are attached, form a carbocyclicring having from 3 to 6 carbons.

In some embodiments, the compound is a compound of formula I, wherein Y₁and Y₂ are both —COOH. In some embodiments Y₁ and Y₂ are both —CH₂OH. Insome embodiments Y₁ and Y₂ are both -tetrazole. In some embodiments Y₁and Y₂ are both —CH₂(OH). In some embodiments Y₁ and Y₂ are both —COOR₅and R₅ is C₁-C₆ alkyl. In some embodiments Y₁ and Y₂ are both —COOR₅ andR₅ is C₂-C₆ alkenyl. In some embodiments Y₁ and Y₂ are both —COOR₅ andR₅ is C₂-C₆ alkynyl.

In another embodiment, the compound is a compound of formula I, whereinn and m are the same integer, and R₁, R₂, R₃, and R₄ independently areC₁-C₆ alkyl. In yet another embodiment, the compound is a compound offormula I, wherein Y₁ and Y₂ are the same and are —COOH or —COOR₅, andR₅ is C₁-C₆ alkyl. In a preferred embodiment, the compound is a compoundof formula I, wherein Y₁ and Y₂ are COOH, R₁, R₂, R₃, and R₄ are methyl,and n and m are the same and are an integer selected from 2, 3, 4, or 5,preferably n and m are the same and are 4 or 5. Most preferably n and mare 4. In still another embodiment, the compound is a compound offormula I, wherein Y₁ and Y₂ are —COOH, and R₁, R₂, R₃, and R₄independently are C₁-C₆ alkyl, and n and m are 4. In another embodimentthe compound is a compound of formula I, wherein Y₁ and Y₂ are —COOH, nand m are 4, R₁, R₂, R₃, and R₄ are methyl. In another embodiment thecompound is a compound of formula I, wherein Y₁ and Y₂ are —COOH, n andm are 5, R₁, R₂, R₃, and R₄ are methyl. In yet another embodiment, thecompound is a compound of formula I, wherein Y₁ and Y₂ are —CH₂OH, and nand m are 4. In another embodiment, the compound is a compound offormula I, wherein Y₁ and Y₂ are —CH₂OH, n and m are 4 and R₁, R₂, R₃,and R₄ are methyl.

Compounds of formula (I) can be referred to generally ascarboxyalkylethers. Carboxyalkylethers are a class of compoundsdescribed by Bisgaier et al. in U.S. Pat. No. 5,648,387, and by Ando etal. in U.S. Pat. No. 6,861,555, both patents are incorporated herein byreference. These compounds are described as having a number ofbiological activities, including raising levels of high densitylipoproteins (HDL), and are said to be useful for treatingcardiovascular disorders, diabetes, and other medical conditions. Thecompounds can be used alone or in combination with other agents such asstatins, for example as described by Bisgaier et al. in U.S. PatentPublication No. 2002/0103252, which is incorporated herein by reference.

In one embodiment of this invention, the compound of formula (I) is acompound known as “Cl-1027”, as “gemcabene”, and as “PD 72953” (Bays et.al., Am. J. Cardiol. (2003); Vol. 92, pp 538-543, incorporated herein byreference). The chemical name of this compound is6,6′-oxybis-(2,2′-dimethylhexanoic acid) or alternately6-(5-carboxy-5-methyl-hexyloxy)-2,2-dimethylhexanoic acid.

In another embodiment gemcabene is administered as a pharmaceuticalsalt. In yet another embodiment, gemcabene is administered as a calciumsalt.

In another embodiment gemcabene is administered as the anhydrousmonocalcium salt. The structure of the anhydrous monocalcium salt ofgemcabene is:

In an embodiment gemcabene is administered as a hydrate. In anotherembodiment gemcabene is administered as the hydrate of the monocalciumsalt, as described in U.S. Pat. No. 6,861,555. The structure of thehydrate of the monocalcium salt of gemcabene is:

In another embodiment, gemcabene is administered in a crystalline form.

Another embodiment of the invention is a method of lowering the plasmaLDL-C level in a patient on a stable dose of statin, the patient havingan LDL-C level above treatment goal, comprising administering to thepatient, an effective amount of gemcabene.

Another embodiment of the invention is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of gemcabene, wherein the patient is on a stabledose of statin and the patient has an LDL-C level above treatment goal.

Yet another embodiment is a method of preventing, delaying the onset of,or reducing the severity of a secondary cardiovascular event comprisingadministering to a patient in need thereof, an effective amount ofgemcabene, wherein the patient is on a stable dose of statin and thepatient has an LDL-C level above treatment goal.

Another embodiment of the invention is a method of lowering the plasmaLDL-C level in a patient on a stable dose of statin, the patient havingan LDL-C level above treatment goal, comprising administering to thepatient, an effective amount of a calcium salt of gemcabene.

Another embodiment of the invention is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of a calcium salt of gemcabene, wherein the patientis on a stable dose of statin and the patient has an LDL-C level abovetreatment goal.

Yet another embodiment is a method of preventing, delaying the onset of,or reducing the severity of a secondary cardiovascular event comprisingadministering to a patient in need thereof, an effective amount of acalcium salt of gemcabene, wherein the patient is on a stable dose ofstatin and the patient has an LDL-C level above treatment goal.

Another embodiment of the invention is a method of lowering the plasmaLDL-C level in a patient on a stable dose of statin, the patient havingan LDL-C level above treatment goal, comprising administering to thepatient, an effective amount of gemcabene-monocalcium salt.

Another embodiment of the invention is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of gemcabene-monocalcium salt, wherein the patientis on a stable dose of statin and the patient has an LDL-C level abovetreatment goal.

Yet another embodiment is a method of preventing, delaying the onset of,or reducing the severity of a secondary cardiovascular event comprisingadministering to a patient in need thereof, an effective amount ofgemcabene-monocalcium salt, wherein the patient is on a stable dose ofstatin and the patient has an LDL-C level above treatment goal.

Therefore another embodiment of the invention is a method of loweringthe plasma LDL-C level in a patient on a stable dose of statin, thepatient having an LDL-C level above treatment goal, comprisingadministering to the patient, an effective amount of gemcabene or anester or a salt thereof, or a precursor thereof that metabolizes in vivoto the compound, or the free acid, a salt, or a hydrate thereof.

Another embodiment of the invention is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of gemcabene or an ester or a salt thereof, or aprecursor thereof that metabolizes in vivo to the compound of formula(I) or the free acid, a salt, or a hydrate thereof; wherein the patientis on a stable dose of statin and the patient has an LDL-C level abovetreatment goal.

Yet another embodiment is a method of preventing, delaying the onset of,or reducing the severity of a secondary cardiovascular event comprisingadministering to a patient in need thereof, an effective amount ofgemcabene or an ester or a salt thereof, or a precursor thereof thatmetabolizes in vivo to the compound of formula (I) or the free acid, asalt, or a hydrate thereof; wherein the patient is on a stable dose ofstatin and the patient has an LDL-C level above treatment goal.

In another embodiment the compound of formula (I) is:

or a salt thereof. (See Mueller R. et al. J. Med. Chem., 2004, 47 (21),pp 5183-5197).

Another compound useful in the methods of the present invention is acompound known as ESP 55016 and alternately as ETC 1002. ESP 55016 whichis described in Cramer, C. T., et al. J. Lipid Res. 2004, 45:1289-1301.The structure of ESP 55016 is:

ESP 55016 was shown to be effective in lowering non-HDL-C, raisingHDL-C, and decreasing triglyceride levels in obese female Zucker rats.Also useful in the present invention are pharmaceutically acceptablesalts or an ester of ESP 55016.

Therefore another embodiment of the invention is a method of loweringthe plasma LDL-C level in a patient on a stable dose of statin, thepatient having an LDL-C level above treatment goal, comprisingadministering to the patient, an effective amount of the compound:

or an ester or a salt thereof, or a precursor thereof that metabolizesin vivo to the compound, or the free acid, a salt, or a hydrate thereof.

Another embodiment of the invention is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of the compound:

or an ester or a salt thereof, or a precursor thereof that metabolizesin vivo to the compound of formula (I) or the free acid, a salt, or ahydrate thereof; wherein the patient is on a stable dose of statin andthe patient has an LDL-C level above treatment goal.

Yet another embodiment is a method of preventing, delaying the onset of,or reducing the severity of a secondary cardiovascular event comprisingadministering to a patient in need thereof, an effective amount of thecompound:

or an ester or a salt thereof, or a precursor thereof that metabolizesin vivo to the compound of formula (I) or the free acid, a salt, or ahydrate thereof; wherein the patient is on a stable dose of statin andthe patient has an LDL-C level above treatment goal.

Other compounds useful in the methods of the present invention arecompounds of formula (II):

wherein n and m are an integer from 3-5; each of R₁, R₂, R₃, and R₄ isindependently methyl, phenyl, 4-methyl-phenyl, and 4-butyl-phenyl; Y₁and Y₂ independently are —COOH, —CH₂OH, tetrazole, and —COOR₅; R₅ isC₁-C₆ alkyl, C₂-C₆ alkenyl, C₂-C₆ alkynyl; or an ester or a saltthereof.

Compounds of formula (II) have been disclosed and described as lipidlowering agent. (See Mueller R. et al., J. Med. Chem. (2004), Vol. 47(21), pp 5183-5197)

Other compounds useful in the methods of the present invention arecompounds of formula (III):

wherein n, and m independently are integers from 4 to 7; each occurrenceof R₁, R₂, R₃, and R₄ is independently C₁-C₆ alkyl, C₂-C₆ alkenyl, C₂-C₆alkynyl, or R₁ and R₂ taken together with the carbon to which they areattached, form a carbocyclic ring having from 3 to 6 carbons, or R₃ andR₄ together with the carbon to which they are attached, form acarbocyclic ring having from 3 to 5 carbons; R is H or C₁-C₆ alkyl; oran ester or a salt thereof, or a precursor thereof that metabolizes invivo to the compound of formula (III) or the free acid, a salt, or ahydrate thereof.

Specific compounds of formula (III) include:

and salts or esters thereof, or a precursor thereof that metabolizes invivo to the compound of formula (III) or the free acid, a salt, or ahydrate thereof.

Compounds of formula (III) have been disclosed and described as lipidlowering agents. (See Bell R. P. L. et al., Bioorg. Med. Chem. (2005),Vol. 13, pp 223-236 and Oniciu et al., J. Med. Chem. (2006), Vol. 49,No. 1, pp 334-348).

Compounds useful in the methods of the invention also include precursorsor pro-drugs of the compounds of the present disclosure, namelycompounds that when administered to a subject are metabolized orotherwise converted in vivo to the free acid, salt, or hydrate thereof.See Goel, U.S. Pat. No. 7,345,190 “Carnitine conjugates as dual prodrugsand uses thereof”, incorporated herein by reference. Other compoundsthat are metabolized in situ include those described in U.S. Pat. Nos.6,410,802, 6,459,003, 6,645,170, 6,713,507, 6,790,953 and 7,192,940, allof which are incorporated herein by reference.

In some cases patients may be or may become intolerant or resistant tostatin therapy. In some cases the patient experience adverse events, forexample, muscle pain, myopathy or rhabdomyloysis, increased levels ofserum alanine aminotransferase (ALT). In such cases, statin use may becontraindicated. It is contemplated that for these patients, monotherapywith the compounds of the invention can be administered and LDL-Clowering achieved. In general, adverse events associated with statinsincrease in frequency and severity with increasing dose of statin.

In some cases a patient receiving a statin may not achieve goal becausethe patient is being treated at the maximum dose of statin tolerated bythat patient which is insufficient to obtain the desired result. Thecompounds of the invention are contemplated for use in such patients.One of skill in the art would understand that combination treatment of astatin and a compound of the invention could be useful in furtherlowering LDL-C while the patient is treated at the maximum tolerateddose of statin even where that dose is lower than the maximum alloweddose.

It is contemplated that any of the foregoing method can be used to treata patient with one or more of the following conditions: coronary heartdisease or a coronary heart risk equivalent, or has had a previousprimary cardiovascular event, or a previous cerebral vascular event. Orthe patient is being treated by any of the methods of the disclosure hasas a risk factor, smokes, has hypertension, is undergoing treatment withan antihypertensive medication, has an HDL cholesterol level less than40 mg/dL, has a family history of premature coronary heart disease, is amale ≥45 years or a female ≥55 years of age.

One embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, wherein the patient has a 10-yearrisk for coronary heart disease of ≥10%, or ≥20%, or ≥25%, or ≥30%,comprising administering to the patient, an effective amount of acompound of formula (I). Another embodiment is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, wherein the patient has a 10-year riskfor coronary heart disease of ≥10%, or ≥20%, or ≥25%, or ≥30%,comprising administering to the patient an effective amount of acompound of formula (I). Yet another embodiment is a method ofpreventing, delaying the onset of, or reducing the severity of asecondary cardiovascular event, wherein the patient has a 10-year riskfor coronary heart disease of ≥10%, or ≥20%, or ≥25%, or ≥30%,comprising administering to the patient an effective amount of acompound of formula (I).

One embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, wherein the patient has an LDL-Clevel of ≥70 mg/dL, or ≥100 mg/dL, or ≥115 mg/dL, or ≥130 mg/dL, or ≥160mg/dL, or ≥240 mg/dL, comprising administering to the patient, aneffective amount of a compound of formula (I). Another embodiment is amethod of decreasing a patient's risk for developing coronary heartdisease or having a recurrent cardiovascular event, wherein the patienthas an LDL-C level of ≥70 mg/dL, or ≥100 mg/dL, or ≥115 mg/dL, or ≥130mg/dL, or ≥160 mg/dL, or ≥240 mg/dL, comprising administering to thepatient an effective amount of a compound of formula (I). Yet anotherembodiment is a method of preventing, delaying the onset of, or reducingthe severity of a secondary cardiovascular event, wherein the patienthas an LDL-C level of ≥70 mg/dL, or ≥100 mg/dL, or ≥115 mg/dL, or ≥130mg/dL, or ≥160 mg/dL, or ≥240 mg/dL, comprising administering to thepatient an effective amount of a compound of formula (I).

Another embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, wherein the patient has an LDL-Clevel between about 70 mg/dL and about 100 mg/dL, or between about 70mg/dL and about 115 mg/dL, or between about 115 mg/dL and about 130mg/dL, or between about 130 mg/dL and about 160 mg/dL, or between about160 mg/dL and about 240 mg/dL, comprising administering to the patient,an effective amount of a compound of formula (I). Another embodiment isa method of decreasing a patient's risk for developing coronary heartdisease or having a recurrent cardiovascular event, wherein the patienthas LDL-C level between about 70 mg/dL and about 100 mg/dL, or betweenabout 70 mg/dL and about 115 mg/dL, or between about 115 mg/dL and about130 mg/dL, or between about 130 mg/dL and about 160 mg/dL, or betweenabout 160 mg/dL and about 240 mg/dL, comprising administering to thepatient an effective amount of a compound of formula (I). Yet anotherembodiment is a method of preventing, delaying the onset of, or reducingthe severity of a secondary cardiovascular event, wherein the patienthas an LDL-C level between about 70 mg/dL and about 100 mg/dL, orbetween about 70 mg/dL and about 115 mg/dL, or between about 115 mg/dLand about 130 mg/dL, or between about 130 mg/dL and about 160 mg/dL, orbetween about 160 mg/dL and about 240 mg/dL, comprising administering tothe patient an effective amount of a compound of formula (I).

Another embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, wherein the patient is diabetic,comprising administering to the patient, an effective amount of acompound of formula (I). Another embodiment is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, wherein the patient is diabetic,comprising administering to the patient an effective amount of acompound of formula (I). Yet another embodiment is a method ofpreventing, delaying the onset of, or reducing the severity of asecondary cardiovascular event, wherein the patient is diabetic,comprising administering to the patient an effective amount of acompound of formula (I).

Another embodiment is one embodiment is a method of lowering the plasmaLDL-C level in a patient on a stable dose of statin, wherein the patienthas an HDL cholesterol level less than 40 mg/dL and blood triglycerideslevels ≥150 mg/dL, comprising administering to the patient, an effectiveamount of a compound of formula (I). Another embodiment is a method ofdecreasing a patient's risk for developing coronary heart disease orhaving a recurrent cardiovascular event, wherein the patient has an HDLcholesterol level less than 40 mg/dL and blood triglycerides levels ≥150mg/dL, comprising administering to the patient an effective amount of acompound of formula (I). Yet another embodiment is a method ofpreventing, delaying the onset of, or reducing the severity of asecondary cardiovascular event, wherein the patient has an HDLcholesterol level less than 40 mg/dL and blood triglycerides levels ≥150mg/dL, comprising administering to the patient an effective amount of acompound of formula (I).

Another embodiment is one embodiment is a method of lowering the plasmaLDL-C level in a patient on a stable dose of statin, wherein the patienthas metabolic syndrome, comprising administering to the patient, aneffective amount of a compound of formula (I). Another embodiment is amethod of decreasing a patient's risk for developing coronary heartdisease or having a recurrent cardiovascular event, wherein the patienthas metabolic syndrome, comprising administering to the patient aneffective amount of a compound of formula (I). Yet another embodiment isa method of preventing, delaying the onset of, or reducing the severityof a secondary cardiovascular event, wherein the patient has metabolicsyndrome, comprising administering to the patient an effective amount ofa compound of formula (I).

Another embodiment is one embodiment is a method of lowering the plasmaLDL-C level in a patient on a stable dose of statin, wherein the patientis administered one or more additional cholesterol lowering drugsindependently selected from a cholesterol absorption inhibitor, a bileacid sequestrant, a cholesteryl ester transfer protein inhibitor, amicrosomal triglyceride transfer protein inhibitor, a miR-33 inhibitor,a PCSK9 inhibitor, a squalene synthase inhibitor and an apoB synthesisinhibitor, comprising administering to the patient, an effective amountof a compound of formula (I). Another embodiment is a method ofdecreasing a patient's risk for developing coronary heart disease orhaving a recurrent cardiovascular event, wherein the patient isadministered one or more additional cholesterol lowering drugsindependently selected from a cholesterol absorption inhibitor, a bileacid sequestrant, a cholesteryl ester transfer protein inhibitor, amicrosomal triglyceride transfer protein inhibitor, a miR-33 inhibitor,a PCSK9 inhibitor, a squalene synthase inhibitor and an apoB synthesisinhibitor, comprising administering to the patient an effective amountof a compound of formula (I). Yet another embodiment is a method ofpreventing, delaying the onset of, or reducing the severity of asecondary cardiovascular event, wherein the patient is administered oneor more additional cholesterol lowering drugs independently selectedfrom a cholesterol absorption inhibitor, a bile acid sequestrant, acholesteryl ester transfer protein inhibitor, a microsomal triglyceridetransfer protein inhibitor, a miR-33 inhibitor, a PCSK9 inhibitor, asqualene synthase inhibitor, and an apoB synthesis inhibitor, comprisingadministering to the patient an effective amount of a compound offormula (I).

In some embodiments the additional cholesterol lowering drug isezetimibe, cholestryamine, or Vytorin.

The effective daily dose of a compound of the present invention istypically from about 0.1 mg/kg to about 100 mg/kg. The daily dosetypically utilized for administration to a human subject is betweenabout 25 and about 1200 mg, or between about 50 and about 1000 mg, orbetween about 50 and about 900 mg, or between about 100 and about 900mg, or between about 100 and about 600 mg, or between about 150 andabout 600 mg, or about 150 mg, or about 300 mg, or about 600 mg, orabout 900 mg, or between 10 and 1500 mg, or between 25 and 1200 mg, orbetween 50 and 1000 mg, or between 50 and 900 mg, or between 100 and 900mg, or between 100 and 600 mg, or between 150 and 600 mg, or 150 mg, or300 mg, or 600 mg, or 900 mg. The daily dose can be by non-limitingexample, 25 mg, or 30 mg, or 35 mg, or 40 mg, or 45 mg, or 50 mg, or 55mg, or 60 mg, or 65 mg, or 70 mg, or 75 mg, or 80 mg, or 85 mg, or 90mg, or 95 mg, or 100 mg, 125 mg, or 150 mg, or 175 mg, or 200 mg, or 225mg, or 250 mg, or 275 mg, or 300 mg, or 325 mg, or 350 mg, or 375 mg, or400 mg, or 425 mg, or 450 mg, or 475 mg, or 500 mg, or 525 mg, or 550mg, or 575 mg, or 600 mg, or 625 mg, or 650 mg, or 675 mg, or 700 mg, or725 mg, or 750 mg, or 775 mg, or 800 mg, or 825 mg, or 850 mg, or 875mg, or 900 mg, or 925 mg, or 975 mg, or 1000 mg, or 1025 mg, or 1050 mg,or 1075 mg, or 1100 mg, or 1125 mg, or 1150 mg, or 1175 mg, or 1200 mg.For gemcabene the preferred daily dose is 150 mg, or 300 mg, 600 mg or900 mg. The compounds of the present disclosure may be administered 1,2, 3, 4 or 5 times per day. Preferably the compounds are administered 1or 2 times a day. More preferably the compounds are administered 1 timeper day. In any of the foregoing embodiments the statin is atorvastatin,lovastatin, simvastatin, pravastatin, rosuvastatin, fluvastatin,pitavastatin or any combination thereof.

Another embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, comprising administering to thepatient, an effective amount of a gemcabene. Another embodiment is amethod of decreasing a patient's risk for developing coronary heartdisease or having a recurrent cardiovascular event, comprisingadministering to the patient, an effective amount of a gemcabene. Yetanother embodiment is a method of preventing, delaying the onset of, orreducing the severity of a secondary cardiovascular event, comprisingadministering to the patient, an effective amount of a gemcabene.

Another embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, comprising administering to thepatient, an effective amount of a gemcabene, wherein the gemcabene isadministered as a calcium salt. Another embodiment is a method ofdecreasing a patient's risk for developing coronary heart disease orhaving a recurrent cardiovascular event, comprising administering to thepatient, an effective amount of a gemcabene, wherein the gemcabene isadministered as a calcium salt. Yet another embodiment is a method ofpreventing, delaying the onset of, or reducing the severity of asecondary cardiovascular event, comprising administering to the patient,an effective amount of a gemcabene, wherein the gemcabene isadministered as a calcium salt.

Another embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, comprising administering to thepatient, an effective amount of a gemcabene, wherein the gemcabene isadministered as a monocalcium salt. Another embodiment is a method ofdecreasing a patient's risk for developing coronary heart disease orhaving a recurrent cardiovascular event, comprising administering to thepatient, an effective amount of a gemcabene, wherein the gemcabene isadministered as a monocalcium salt. Yet another embodiment is a methodof preventing, delaying the onset of, or reducing the severity of asecondary cardiovascular event, comprising administering to the patient,an effective amount of a gemcabene, wherein the gemcabene isadministered as a monocalcium salt.

Another embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, comprising administering to thepatient, an effective amount of a gemcabene and the daily dose is 150mg, or 300 mg, 600 mg or 900 mg. Another embodiment is a method ofdecreasing a patient's risk for developing coronary heart disease orhaving a recurrent cardiovascular event, comprising administering to thepatient, an effective amount of a gemcabene and the daily dose is 150mg, or 300 mg, 600 mg or 900 mg. Yet another embodiment is a method ofpreventing, delaying the onset of, or reducing the severity of asecondary cardiovascular event, comprising administering to the patient,an effective amount of a gemcabene and the daily dose is 150 mg, or 300mg, 600 mg or 900 mg.

Another embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, comprising administering to thepatient, an effective amount of a gemcabene, wherein the gemcabene isadministered as a calcium salt and the daily dose is 150 mg, or 300 mg,600 mg or 900 mg. Another embodiment is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of a gemcabene, wherein the gemcabene isadministered as a calcium salt and the daily dose is 150 mg, or 300 mg,600 mg or 900 mg. Yet another embodiment is a method of preventing,delaying the onset of, or reducing the severity of a secondarycardiovascular event, comprising administering to the patient, aneffective amount of a gemcabene, wherein the gemcabene is administeredas a calcium salt and the daily dose is 150 mg, or 300 mg, 600 mg or 900mg.

Another embodiment is a method of lowering the plasma LDL-C level in apatient on a stable dose of statin, comprising administering to thepatient, an effective amount of a gemcabene, wherein the gemcabene isadministered as a monocalcium salt and the daily dose is 150 mg, or 300mg, 600 mg or 900 mg. Another embodiment is a method of decreasing apatient's risk for developing coronary heart disease or having arecurrent cardiovascular event, comprising administering to the patient,an effective amount of a gemcabene, wherein the gemcabene isadministered as a monocalcium salt and the daily dose is 150 mg, or 300mg, 600 mg or 900 mg. Yet another embodiment is a method of preventing,delaying the onset of, or reducing the severity of a secondarycardiovascular event, comprising administering to the patient, aneffective amount of a gemcabene, wherein the gemcabene is administeredas a monocalcium salt and the daily dose is 150 mg, or 300 mg, 600 mg or900 mg.

It should be understood that a specific dosage and treatment regimen forany particular patient will depend upon a variety of factors, includingthe activity of the specific compound employed, the age, body weight,general health, sex, diet, time of administration, rate of excretion,drug combination and the judgment of the treating physician, and theseverity of the particular disease being treated. The amount of thecompound administered will also depend upon the particular compound inthe composition.

With reference to any of the foregoing embodiments, preferredembodiments include where the compound of formula (I) is gemcabene, orthe compound of formula (I) is the calcium salt of gemcabene, or thecompound of formula (I) is the monocalcium salt of gemcabene.

Compounds useful in the present invention can be formulated aspharmaceutical compositions and administered to a subject, such as ahuman subject in a variety of forms adapted to the chosen route ofadministration, i.e., orally, transdermal, and parenterally, byintravenous, intramuscular, or subcutaneous routes. Such compositionsand methods for their preparation are well known and may be found, forexample, in Remington's Pharmaceutical Sciences, 19th Edition (MackPublishing Company, 1995). For example, typical formulations forgemcabene are described in U.S. Pat. No. 5,648,387. In one embodiment,gemcabene is formulated with common excipients and carriers such asstarch, binders, diluents and the like, and molded into tablets, orencapsulated into gelatin capsules, all for convenient oraladministration. Gemcabene has excellent physical properties that enableformulation as syrups, elixirs, slow release lozenges and other commonoral formulation types. Gemcabene can additionally be formulated withsaline and other common excipients for administration by the intravenousroute, intraperitoneal and similar parenteral routes. Transdermalpatches can be made with binders and common adjuvants, and rectalformulations using pharmaceutically acceptable waxes can be madeutilizing common formulation technologies that are well known to thoseskilled in the art of pharmaceutical formulations.

The number of references relating to lowering of LDL-C is great and theparameters in the studies can be very different. The discussion of thereferences below is not meant to be exhaustive but rather to illustratethe art regarding two points that are particularly relevant to theinterpretation of the data in the present application. The first beingthat the lowering of LDL-C is not a linear process. Doubling the dose ofLDL-C lowering agent does not necessarily result in a doubling of LDL-Clowering. Second, statins are very effective in lowering LDL-C andadditional lowering seen beyond that of a statin is generally minimal,from about 1% to about 17%, as discussed in the references discussedbelow.

McKenney J. M., Am. J. Ther. (2004), Vol. 11, pp 55-59, notes that“Statins have a nonlinear dose-response relationship, such that doublingthe dose of a particular statin will provide a further reduction inLDL-C of approximately 6%.” Pauciullo, P. et al. (Atherosclerosis(2000), Vol. 150, pp 429-436, at page 432), discloses data regardingcholesterol lowering with the combination of fluvastatin andbezafibrate. Fluvastatin (40 mg) alone gave LDL-C lowering of 22.5% andbezafibrate (400 mg) alone gave a lowering of 9.6%. The combinationprovided only a 23.6% lowering- an incremental change of only 1.1% (notstatistically significant). Illingworth and Bacon (Circulation (1989);Vol. 79, pp 590-596, at page 593), lovastatin (40 mg twice daily)lowered LDL-C by 35.5% where as lovastatin+gemfibrozil (600 mg twicedaily) lowered LDL-C by 39.6% providing only an additional LDL-Clowering of 4.1% (not statistically significant). Jones, P. H. (Clin.Lipidol. (2009), Vol. 4(6), pp 699-711) reported that the addition of135 mg of fenofibrate to a low dose of statin raised LDL-C levels from−39.9% (statin alone) to −33.1%, a difference of 0.8% (not statisticallysignificant). Jones also reported that the addition of 135 mg offenofibrate to a moderate dose of statin raised LDL-C levels from −40.6%(statin alone) to −34.6%, a difference of 5.1%. A combination ofezetimibe and statin showed a greater affect. Stein, E., Eur. Heart J.Suppl. (2001); Vol. 3 (suppl E), pp E11-16, reported that as amonotherapy simvastatin, 10 mg, lowered LDL-C by 35% and ezetimibe, 10mg, lowered LDL-C by 16% while the combination of simvastatin andezetimibe (a cholesterol absorption inhibitor) lowered LDL-C by 52%, adifference of 17%.

EXAMPLES Example 1 Gemcabene Further Lowers LDL-C in Patients notReaching Goal on Statin Therapy

An 8-week, double-blind, placebo-controlled, randomized, multicenter,phase 2 study in hypercholesterolemic patients on a stable dose ofstatin (on statin therapy for at least the previous 3 months) wasconducted to evaluate the efficacy of gemcabene in the further reductionof LDL-C in these patients.

A total of 66 hypercholesterolemic patients were treated in this study:22 randomized to gemcabene 900 mg, 20 randomized to gemcabene 300 mg,and 24 randomized to placebo.

Patients included in the study were men and women ≥18 and ≤65 years ofage with hypercholesterolemia and an LDL-C level at screening of ≥130mg/dL while on a stable (3-months) dose of a statin. Patients wererequired to maintain their current dose of statin throughout the courseof the study.

Patients were excluded for any of the following reasons: women withchildbearing potential; ages >65 and <18 years; triglycerides >400mg/dL; creatinine phosphokinase levels >3 times the upper limit ofnormal (ULN); body mass index >35; any of the following within 1 monthof enrolling into the study: myocardial infarction, severe or unstableangina pectoris, coronary angioplasty, coronary artery bypass graft, orany other major cardiovascular event resulting in hospitalization;uncontrolled diabetes mellitus (HbA_(1c)>10%), renal dysfunction,hepatic dysfunction, history of gall stones or gall bladder disease;known hypersensitivity to a lipid-altering agent; participation inanother clinical study concurrently or within 30 days prior to thescreening visit; taking excluded medications/supplements, abnormalitiesinvestigator feels may compromise the patient's safety or successfulparticipation in the study.

Study medication in tablet form was taken orally during the 8-weekdouble-blind phase of the study. Patients were randomized to 1 of 3treatment groups: Placebo plus concomitant statin, gemcabene 300 mg QDplus concomitant statin, and gemcabene 900 mg QD plus concomitantstatin. The dose of concomitant statin therapy was to remain constantthroughout the study.

Percent change from base line was calculated as follows:

Percent Change From Baseline=[(final value−baseline value)/baselinevalue]×100%.

Baseline values were defined as the mean of the 2 lipid measurementsobtained at screening and Week 0. Final lipid values were obtained atweek 8.

LDL-C Efficacy Results: gemcabene at 300 and 900 mg per daysignificantly lowered LDL-C from baseline at Week 8 by a median of 24.8%and 31.0% respectively, compared with a placebo reduction of 7.9% (bothp<0.01). Results are shown in Table 3.

These data are particularly surprising in view of a previous publishedstudy that showed that co-administration of 300, 600, and 900 mggemcabene with atorvastatin (aggregated over the dose range of 10, 40and 80 mg of atorvastatin) resulted in a decrease in LDL-C beyondatorvastatin monotherapy of 3.8%, 6.1% and 7.4% respectively (seeMandema et al., AAPS Journal 2005; 7(3) Article 52(http://www.aapsj.org).

TABLE 3 Percent Change From Baseline in LDL-C at Week 8^(a) gemcabene +Statin Lipid Parameter Placebo + Statin 300 mg QD 900 mg QD N N = 22 N =18 N = 21 Median Baseline 153.3 143.5 142.5 Median Week 8 137 101.5 103Median % change -7.9 -24.8 -31.0 p-Value N/A 0.005 <0.001 ^(a)Evaluablepatients only, Week 8 of double-blind treatment or last observationcarried forward (LOCF) if Week 8 is missing

The patients' Framingham Risk Score was calculated at baseline. TheFramingham risk score calculation takes into account: age, gender,systolic blood pressure level (+/−treatment), HDL cholesterol level, andsmoker status. After eight weeks, the Framingham Risk Score wasreassessed and showed significant improvement in both statin plusgemcabene groups but not in the statin plus placebo group. Significancewas determined using the SAS Proc Univariate which provides p valuesfrom the student's paired t-test and the Wilcoxon Signed Rank test.

Framingham Results: As shown in Table 4, treatment with gemcabene at 300mg and 900 mg QD significantly reduced the Framingham Risk Scorecompared with statin treatment alone.

TABLE 4 Reduction in Framingham Risk Score with Gemcabene Treatmentgemcabene + Statin Lipid Parameter Placebo + Statin 300 mg QD 900 mg QDN N = 24 N = 19 N = 19 Risk Points 0.75 1.95 3.21 Mean differencep-Value Student's 0.1279 0.0068 <0.0001 paired t-test p-Value SignedRank 0.1519 0.0061 <0.0001

1. A method of decreasing a patient's risk for developing coronary heartdisease or having a recurrent cardiovascular event, comprisingadministering to the patient an effective amount of the compound:

or an ester, or a salt, or a hydrate thereof, wherein the patient is ona stable dose of statin.
 2. A method of preventing, delaying the onsetof, or reducing the severity of a secondary cardiovascular event,comprising administering to a patient in need thereof, an effectiveamount of the compound:

or an ester, or a salt, or a hydrate thereof, wherein the patient is ona stable dose of statin.
 3. The method according to claim 1, wherein thepatient has an LDL-C level above treatment goal. 4-9. (canceled)
 10. Themethod according to claim 3, wherein the patient has coronary heartdisease or a coronary heart risk equivalent, or has had a previousprimary cardiovascular event, or a previous cerebral vascular event. 11.The method according to claim 10, wherein the patient has one or morerisk factors selected from the group consisting of smoking,hypertension, treatment with an antihypertensive medication, HDLcholesterol level less than 40 mg/dL, family history of prematurecoronary heart disease, male at least 45 years, and female at least 55years.
 12. The method according to claim 10, wherein the patient has a10-year risk for coronary heart disease of at least 10%.
 13. (canceled)14. The method according to claim 10, wherein the patient's FraminghamRisk Score is reduced by at least 1 point.
 15. The method according toclaim 10, wherein the patient is diabetic.
 16. The method according toclaim 10, wherein the patient has an HDL cholesterol level less than 40mg/dL and a blood triglyceride levels at least 150 mg/dL.
 17. The methodaccording to claim 10, wherein the patient is administered one or moreadditional cholesterol lowering drug is-independently selected from thegroup consisting of: a cholesterol absorption inhibitor, a bile acidsequestrant, a cholesteryl ester transfer protein inhibitor, amicrosomal triglyceride transfer protein inhibitor, a PCSK9 inhibitor, amicroRNA-33 inhibitor, a squalene synthase inhibitor and an apoBsynthesis inhibitor. 18-20. (canceled)
 21. The method according to claim3, wherein the compound is a calcium salt of gemcabene.
 22. The methodaccording to claim 3, wherein the compound is the monocalcium salt ofgemcabene.
 23. The method according to claim 2, wherein the patient hasan LDL-C level above treatment goal.
 24. The method according to claim23, wherein the patient has coronary heart disease or a coronary heartrisk equivalent, or has had a previous primary cardiovascular event, ora previous cerebral vascular event.
 25. The method according to 24,wherein the patient has one or more risk factors selected from the groupconsisting of smoking, hypertension, treatment with an antihypertensivemedication, HDL cholesterol level less than 40 mg/dL, family history ofpremature coronary heart disease, male at least 45 years, and female atleast 55 years.
 26. The method according to claim 24, wherein thepatient has a 10-year risk for coronary heart disease of at least 10%.27. The method according to claim 24, wherein the patient's FraminghamRisk Score is reduced by at least 1 point.
 28. The method according toclaim 24, wherein the patient is diabetic.
 29. The method according toclaim 24, wherein the patient has an HDL cholesterol level less than 40mg/dL and a blood triglyceride levels at least 150 mg/dL.
 30. The methodaccording to claim 24, wherein the patient is administered one or moreadditional cholesterol lowering drug independently selected from thegroup consisting of: a cholesterol absorption inhibitor, a bile acidsequestrant, a cholesteryl ester transfer protein inhibitor, amicrosomal triglyceride transfer protein inhibitor, a PCSK9 inhibitor, amicroRNA-33 inhibitor, a squalene synthase inhibitor and an apoBsynthesis inhibitor.
 31. The method according to claim 23, wherein thecompound is a calcium salt of gemcabene.
 32. The method according toclaim 23, wherein the compound is the monocalcium salt of gemcabene. 33.A method of decreasing a patient's Framingham Risk Score, comprisingadministering to a patient on a stable dose of a statin, an effectiveamount of the compound:

or the free acid, a salt, or a hydrate thereof, wherein the patient'sFramingham Risk Score is reduced by at least 1 point following theadministration of the compound.